Background: Domestic violence (DV) is a global health issue leading to adverse health consequences. Still, health systems are often unprepared to address it. Methods: A health systems readiness assessment was conducted using multiple mixed-methods data sources including qualitative interviews, focus-group discussions, structured facility observations, and survey with providers. A cross-country synthesis and comparison across the multiple sources was conducted using a framework thematic approach. Results: Common readiness gaps include unclear and limited guidance on DV, unsupportive leadership structure coupled with limited training and resources. Providers felt unprepared and lacked guidance on how to deal with DV cases, and felt unsupported and unprotected by managers and the organisation. Such organisational and service delivery challenges, in turn, also affected how health providers responded to DV cases leaving them less confident, less knowledgeable and unsure about their roles. Furthermore, providers’ personal beliefs and values on DV and gender roles also impacted on providers’ motivation and their ability to respond prompting some to become ‘activists’ while others reluctant to intervene and prone to blame women. Our synthesis also pointed to a disconnection between women and health services as women had low trust in providers being able to protect confidentiality, feared of being judged, or did not think health services would deal with DV (as it was not a traditional health issue). Conclusions: Our study has shown the importance of having policy clarity on roles and responsibilities for both health managers and clinicians. It also highlighted the need to engage the leadership across every system to reframe challenges, and strengthening routine practices to encourage staff engagement in responding to DV. Future research should also determine the ways in which women, community or organisational preparations are related to later implementation success and how these interact with clients and communities.